Tuberkulosis Anak, DOTS, ISTC. Finny Fitry Yani Courtesy : UKK Respirologi Anak IDAI

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1 Tuberkulosis Anak, DOTS, ISTC Finny Fitry Yani Courtesy : UKK Respirologi Anak IDAI

2 World problems of Tuberculosis (TB) Global problem Neglected Childhood TB Low Case Detection Rate Lack of holistic approach of TB management Non-standardized management

3 Global burden of tuberculosis (TB) 1/3 of the population of the world have been infected Prevalence: million (1990s ) 11.1 million (2008 ) New cases/year: 9.3 million (2007) 9.4 million (2008)

4 GOAL: TUBERCULOSIS PROGRAMS to break the chain of the transmission for eliminating the disease from society. Strategies: 1)case finding and treatment of active disease 2)treatment of LTBI 3)vaccination with BCG

5 National TB Programs (NTPs)= P2 TB Kemenkes Focus on adult cases Pediatric TB

6 DOTS (Directly Observe Treatment Short-course) A global strategy to combat world TB problems Developed by WHO and IUATLD Introduced in early 1990, implemented in Indonesia since 1994s DOTS coverage in 2006: 98%

7 5 KOMPONEN DOTS Komitmen Politis dan dukungan semua pihak Diagnosis mikroskopik Ketersediaan Obat 1 ANAK?? 4 WHO Pencatatan Pelaporan 5 3 Pengawas Menelan Obat

8 Cure rate tinggi (pemutusan rantai transmisi) Paling cost effective (Bank Dunia) Rekomendasi WHO

9 Tujuh Strategi Utama Program Nasional Penanggulangan TB Ekspansi Quality DOTS Equitable Quality DOTS Expansion Indonesia 1. Perluasan & Peningkatan pelayanan DOTS berkualitas 2. Menghadapi tantangan baru, TB-HIV, MDR-TB dll 3. Melibatkan Seluruh Penyedia Pelayanan 4. Melibatkan Penderita & Masyarakat Didukung dg Penguatan Sistem kesehatan 5. Penguatan Policy & Kepemilikan Daerah 6. Kontribusi thd Sistem Pelayanan Kesehatan 7. Penelitian Operasional

10 SEMBUH

11 TB management in Indonesia Healthcare providers Government Private PHCs Government hospitals Private hospitals Private practices BP4 RSP DOTS strategy GP Pulm

12 TB IN HOSPITALS Case finding : high (DIY: hospital 36%; PHCs 27%; BP4 37%) Have no working area Case holding: low high dropped out (>50%) Low cure rate (< 50%) HOSPITAL DOTS LINKAGE (HDL)

13 SITES OF DIAGNOSIS OF TB IN HOSPITAL

14 EXTERNAL NETWORKING CHC PRM / PPM Private Doctors PKK, PPTI NGO Hospitals District Health Service Community Leader Lung Clinics PPTI Clinics, WP,Lapas/Rutan

15 Option of TB management in HDL Option Suspect finding Diagnosis Treatment initiation Continuing treatment Consultation Recording and reporting Hospital/non PHC PHC

16 REFERAL SYSTEM IN HDL Alur Rujukan Penderita Tuberkulosis Koordinator HDL Kab/Kota Wasor TBC Kab/Kota informasi konfirmasi Rumah Sakit Penderita, OAT, TB.01, surat rujukan (TB.09) (TB.09) Puskesmas

17 World problems of Tuberculosis (TB) The second global cause of death from infectious agents Neglected Childhood TB Low Case Detection Rate Lack of holistic approach of TB management Non-standardized management

18 Non-standardized management Diagnosis over diagnosis underdiagnosis Treatment irrational treatment Public Health contact tracing Recording and reporting

19 ISTC (International Standard for TB care) Differ from existing guidelines standards what should be done guidelines how the action is to be accomplished Evidence-based, living document As a complementary of the existing guideline

20 Purpose of ISTC

21 ISTC Diagnosis Treatment Public Health 6 standards 9 standards 2 standards

22 Standards for Diagnosis Pediatric considerations

23 Standard 1 All persons with otherwise unexplained productive cough lasting two-three weeks or more should be evaluated for TB Pediatric consideration COUGH is NOT the main symptom of TB Other symptoms should be considered: weight loss or FTT in the last two months fever >2 weeks with unexplained causes Close contact with adult Pulmonary TB

24 Standard 4 All persons with chest radiographic findings suggestive of TB should have sputum specimens submitted for microbiological examination. Pediatric consideration Collecting sputum in children is challenging If possible, perform induced sputum or gastric lavage

25 Standard 6 The diagnosis of intra-thoracic TB in symptomatic children with negative sputum smears should be based on the finding of chest radiograph Pediatric consideration The appearance of lymphadenopathy is subtle and may be difficult to detect especially in malnourished children and when there is HIVrelated pulmonary disease.

26 Standards for Treatment pediatric considerations

27 Standard 8 All patients (incl those with HIV infection)... regimen using drugs of known bioavailability. The initial phase should consist of two months of isoniazid, rifampicin, pyrazinamide, and ethambutol. Pediatric consideration Triple drugs: INH, Rif and PZA Four or five drugs for severe TB

28 Standards for Public Health

29 ISTC Standard 16 All providers of care for patients with TB should ensure that persons (especially children under 5 year of age and persons with HIV infection) who are in close contact with patients who have infectious TB are evaluated and managed in line with international recommendations.

30 Children under 5 years of age and persons with HIV infection who have been in contact with an infectious case should be evaluated for both latent infection with M. tb and for active TB. ISTC Standard 16

31 ISTC Standard 17 All providers must report both new and retreatment TB cases and their treatment outcomes to local public health authorities, in conformance with applicable legal requirements and policies.

32 Together in partnership we are more than the sum of our parts!